Treatment of osteoporosis in clinical practice: when, whom, how, and for how long

Osteoporosis is a highly prevalent chronic disease associated with an increased risk of fragility fractures and a substantial clinical and socioeconomic burden. Its management is based on fracture risk stratification, integrating clinical risk factors, bone mineral density, and tools such as FRAX®. Previous fragility fracture is the strongest predictor of future fractures and, in most cases, indicates the need for pharmacological treatment. In patients at high risk, antiresorptive agents remain the cornerstone of therapy, whereas in those at very high risk, an initial anabolic strategy followed by antiresorptive treatment should be considered. Treatment duration and sequencing require periodic reassessment, particularly with bisphosphonates and denosumab, whose discontinuation must be carefully planned to avoid rebound effects. This practical approach allows individualized clinical decision-making and aims to optimize fracture prevention, treatment adherence, and long-term outcomes in patients with osteoporosis in routine clinical practice settings.